PICC Nurse, Kristin Hansen

[00:00] Michelle: Kristin Hansen is an enthusiastic, energetic, and highly skilled PICC nurse, but she admits that it wasn't always easy for her to transition from starting IVs on premature babies in the NICU to placing PICC lines on adults. With practice and persistence, she learned everything about this interesting nursing specialty, and we are so lucky she is sharing her knowledge with us. Kristin explained the criteria for becoming a PICC candidate, the technologies used, the teamwork required, professional organizations, and much more. If you're a nurse with decent IV skills, can work independently, and have an affinity for sharp, shiny objects, PICC nursing could be for you. And if your hospital doesn't have a PICC team, step up and start one. In the five-minute snippet: Well, you'll just have to hear this one for yourself.  Well, hi Kristin. Welcome to the podcast.

[01:15] Kristin: Thank you. I'm happy to be here.

[01:18] Michelle: Me too. I am happy that we got together. So our story is we worked together many years ago in the NICU, and then you were so rude and you left. I think I eventually forgave you. So we worked together in the NICU, and then when I started this podcast about a year and a half ago, you said, hey, if you ever need a PICC nurse, let me know. And so here we are a year and a half later.

[01:58] Kristin: Yes, I did say that. And when you messaged me, I was like, uh oh, I know, messaging me, but I'm happy to do it.

[02:11] Michelle: Yes, well, you're the resident expert for today, so we're going to talk a lot about PICC nursing and what that is. But start by just talking about some of your history. Why'd you go into nursing? What departments did you work in? And then how did you get interested in PICC and IV nursing?

[02:34] Kristin: Yeah. When I first knew I really wanted to do something in healthcare, probably in high school, I wasn't quite sure exactly what I wanted to do. I knew that I wanted to help people, whatever that meant. Right? And so in college, I was deciding between physical therapy and nursing, and I was like, man, just thinking about physical therapists and nurses. I just felt like nursing, you spend so much more time with patients and you spend a lot more time with those people. And I just felt called to it. I just felt a pull. And so when I finished nursing school for last semester, at the end we had to do like a capstone or preceptorship, and I knew I wanted to go into pediatrics, but I wasn't sure exactly what that was going to look like for me and where I wanted to go. It just so happened that they were able to take me in, in the NICU at Cook Children's in Fort Worth, Texas. That's where my parents lived at the time, and that's where me and my fiancee at the time, Gabe, were going to end up. He's a nurse as well. So I had my preceptorship there, and I ended up loving it. But it was terrifying because they don't teach NICU nursing in nursing school. There might be, like, just a little glib of it in your OB rotation. And so I felt like I was starting from square one. So it was really intimidating when I did my preceptorship because that whole world was completely new, the diagnoses and the care and everything. But I loved it. I was fascinated by it, and I found that that's something I really liked. I struggled a lot during my first year in nursing. I was worried I made a mistake because it was so hard. It was a hard adjustment for me coming out of school and the reality of what being a nurse looked like. But I learned so much in that first year. And so I was like, well, I mean, is NICU for me? I'm not too know, just kind of second-guessing everything. And then I went into pediatric urgent care, did that for a year, and I was like, oh, my gosh, no. This urgent care setting is, I miss the NICU. I need to get back to that. And Gabe and I, my husband, we had been married for a year, and we were like, you know what? We're young. Let's do travel nursing. And he wasn't too happy, necessarily, where he and I were actually both working at Cook Children's Medical Center in Fort Worth. And then we ended up doing travel nursing out in California. That was where my sister lived. I had all this extended family out there, and so we ended up doing that. I did it for about a year, a little over a year. Worked at different facilities there in mostly northern California, Sacramento, and Roseville, California. Then I worked just Casual or PerDiem, whatever you want to call it, at a NICU up in Roseville, while Gabe was finishing up an assignment at Kaiser Roseville and their pediatric department. And my parents ended up moving from Texas to California, and they ended up moving to Visalia. And I had family in Dinuba and Fresno area, and so that's why they kind of moved out that way. So then Gabe and I decided to get permanent jobs to be closer to them. And that's where I ended up going to Kaweah, and that's where I met you, Michelle, and you also met Gabe. My husband worked in pediatrics, and I worked in the NICU there for a couple of years. Then some personal family stuff came up, and we ended up moving out here to Omaha, Nebraska, where we are currently to be closer to Gabe's mom. And I initially was working in the NICU here between 2018 and 2020. After being at Kaweah, which was such a special unit and a special time for me just in my career, and personally, it was the first place I'd ever worked at that it felt like family. It was such a small group of people who worked really well together. We enjoyed working together. We were a good team. We helped each other out, and I just hadn't really found that ever since. And so it was something that I was craving. And when we moved out here, I missed that so much. Like, I grieved that loss, and I realized how important that was to me. And so it was a really tough transition, moving from just in general geographically, like California to Nebraska, but also leaving that work family and how important that was to me. And I learned so much at Kaweah in my time there. I really struggled to kind of find my place out here and struggled to find that and ignite that passion again. Things are just done differently now, the NICU is the NICU. There's like a base, right? But every place does things differently. Every unit is run differently. Everywhere has different protocols, what works for them, and every unit has its own culture. As much as I love the NICU, I felt like my passion had been kind of draining for me which made me really sad, because I was, like, thinking I was going to be in the NICU forever. This was it. I'm going to die doing this, basically. But I was missing something, and I was missing that camaraderie, but I was also missing just my love and joy of what I did. And I was like, this is a disservice to myself, just as a professional and as a nurse, but also to my patients, too, because people can tell a difference. And I was just like, I need to change. There was this nurse that I worked with on nights, because I was working nights in the NICU, and she had done NICU for 15 years or so, and she had said something about her working part-time on the IV team. At the time I was working at the women's hospital for the Methodist health system here in Omaha. And that's where she was at. We were working at the NICU at a women's hospital, and she was like, I work at the main campus, which is just the main hospital on the IV team. And I was like, oh, wow, that sounds really cool. Let me know if there are any openings. Or I was just, like, saying that kind of in passing, but also just being like, yeah, that actually kind of sounds cool. And I used to be terrified of doing IVS. It's one of those super important skills that's really terrifying to have to do, like, in the moment, especially in the NICU. Like, you lose IV access. It's like, oh, my gosh, we need to get this IV now. Especially if the baby's NPO. We worry about blood sugars, all that. And so there's the pressures on, and so I used to be terrified of that. But then when I was working at Kaweah, this other nurse, Jade, she and I loved doing IVS together. I called her my IV buddy, and because we were at a delivery hospital, we got to do IVS all the time and draw cultures and know labs. And I discovered that the more I did it over and over again, the more I really enjoyed it. I know that kind of sounds, like, sick and twisted, but I really did. I enjoyed the skill, and I found that I was decent at it. And so when that kind of piqued my interest with this coworker, and she ended up leaving the NICU and then going to IV team full time, and probably a few months passed, and I saw a position for IV team because I was just, like, kind of perusing, because I just like to look to see what's out there all the time. And I just was like, I'm going to apply. I'm just going to do it. Let's just see what happens. I let my friend know, and she let the manager know, so I did an interview, and then they actually gave me the opportunity to shadow them for half a day, like 4 hours. And it was so interesting. I had to see a PICC line placed, just see them do their day, just their workflow, the kind of skills and things that they did and tasks. It piqued my interest, for sure. But I was terrified to. I was scared to change after doing NiCU for, gosh, how long did I do NICU at that time? Probably like six or seven years. I'd only done NICU or pediatrics, so then transitioning to IV team was going to be in the adult world, and it was just going to be completely different than anything I'd done before. But I just felt like it was the right decision. I felt it in my core that I needed to do this. And I think that this could be really great. I think this could be maybe the best decision I've made. And I did, and I love it. I'm obsessed.

[12:20] Michelle: I remember when you and Gabe came to Peds and the NICU, and you guys were like, the power couple. Gabe had such great pediatric skills, and then you and the NICU, and I remember you and Jade really kind of tag teaming IVs because you mentioned you really loved it and you thought that was weird, but it's like, no, it's not. Because with repetition, any skill just gets better and better. Right?

[12:54] Kristin: Yeah.

[12:56] Michelle: And so you see those improvements. So going from the pediatric population to the adult population, what was that like?

[13:06] Kristin: That was a huge change for me. I used to have two or three people help me with an IV start, like, in the NICU and the pediatric population, because you usually have to have somebody be your assistant, hand you stuff, somebody hold somebody, give the pacifier. All this really, like, in the adult world, as long as they're compliant, I usually make sure my patients are okay with me poking them before I do it. It's just you and them or just having to talk and have a conversation. I would talk to the babies in the NICU. Right. But it's just totally different. You have somebody there who's going to ask you questions or talk to you, and you don't want to just not say anything to them. Right. And be awkward and just going back to remembering all these adult diagnoses and adult medications and getting used to hearing that and. Oh, yeah, that's what that's for. Because I kind of need to know that when I'm starting an IV, do we need to look into a different option? Like, if it's this medication is hard on your veins, maybe we need to do this or that. And it took some time. That base was there from nursing school, but I had just been in a different world for a long time, so it took a little bit. And also in the NICU, we'd use the trans illuminator light to really see those veins, which, with the skills that, I mean, that's great. And all that, you can see them, but it doesn't tell you the depth of the vein or how big it is, you can kind of see. But then it's hard to tell between arteries and veins sometimes with those trans illuminators, but getting away from that and learning that skill of going by feel, and that was a skill that I had to learn. I remember when I first started on the iv team, I would actually touch my veins on myself and close my eyes and then just kind of get the feel of that bounce. And then I would try to just slowly find that vein, feel it all the way at my arm, and then look down and be like, oh, yeah, I did it. So those are skills that took time to learn on top of just putting an IV and just sticking it in there. But even anatomy, too, where to look on adults is way different than looking at the pediatric population or in the neonate. So that was different. We're not going to look in the scalp or the saphenous, those other places. Some of us NICU nurses like to look so bad was a little different. But I love the actual. The tasks and the skills and doing that, and I'm glad that I enjoyed doing that with adults just as much as I did with the pediatric population.

[16:14] Michelle: Yeah, kids, they're definitely special, and you need a lot of help, a lot of hands. And it's so funny that you're mentioning the trans illuminator that we use all the time in the NICU. And it's funny, when I was starting IVs, when I learned way back in the 1980s, I learned the skill by touch because we didn't have those pieces of technology. And then, of course, many of the newer nurses just coming out of school, they learned with the trans illuminator, I would go in and start an IV, and they would always hand me the trans illuminator, and I'm like, no, I can't use that thing because first of all, I would always blind myself. I'd point it right into my eye, and then I'm like, well, shit, I'm blind anyway. But I don't need the skill of sight to start an IV. So I would just feel it. But it's just a matter, really of what you learn. And sometimes they're good habits, sometimes they're bad habits, and sometimes you have to unlearn them. When you were learning to be a PICC nurse, what was the normal training period that you would go through? And do you have to get a certain number of sticks before you get certified? Talk about that.

[17:43] Kristin: When I first started, so I obviously had an IV background because I worked in the NICU, but doing it in adults was completely different. So my training period for the stuff that we do, which I'll just go over just briefly, kind of everything that we do, and then I'll kind of get into what that training looks like. So we do IVS, obviously routine IV restarts, and the nurses in our hospital are actually really spoiled. A lot of them have taken way advantage of us, which is great because I want to be needed, but a lot of them don't even know how to start their own IV's. So we do a lot of the routine IV restarts, we do all the centraline dressing changes in the whole hospital. We keep track of all those. We access ports, we place PICC lines, and midlines. We also do ultrasound-guided IVs, too. So that training period initially was just to get the hang of doing adult IVS. So doing those, learning how to access ports, doing a sterile dressing change, assisting with picks. PICC's can be placed just by one nurse. Usually, you need at least someone to help or assist in some kind of capacity. But our team, we usually have the inserter, and then the assistant hands you stuff and does paperwork, charting a whole bunch of other stuff. So I was learning how to be the assistant, just learning by watching them place pick lines, and help with midline insertions as well. So that process took about six months of just getting those other tasks down. And then after that, you do an online course. We do it through Bard and it's just this online class you take and you get your certificate and then you do on-the-job training. On-the-job training. Ideally, they want you to have around 20 to 25 successful PICC insertions until you're quote-unquote on your own, which you're never really on your own because you have someone there always with you to help troubleshoot and answer any questions and give any assistance needed. So that's what that looks like. Honestly, it was a lot easier than I thought it was going to be. I was thinking I was going to. Not the, I mean, PICC's. Learning how to do PICC's, was a skill that was just different. But as far as the whole process of getting certified and doing it, I was like, oh, wow. I thought I was going to have to take this big test when I was done with the online portion, but I didn't. It was literally just an online course that you go through and everything else is learned on the job, which is the best learning anyway when you're actually just doing it with somebody there with you. That's obviously a good teacher, but that's what that looks like as far as getting PICC- certified.

[20:53] Michelle: Well, when you come on to shift, first of all, what shift do you work?

[20:59] Kristin: So now I am doing the overnight shift. I do 11p to 7a. I work Monday through Friday we do eight hour shifts, which is really nice. But before I did the day shift, which was 07:00 a.m. To 03:30 p.m. We're the only people actually in the hospital setting that I'm aware of that do eight hour shifts.

[21:26] Michelle: Yeah, those seem a little bit archaic, but I know there are still places that do eight hour shifts.

[21:34] Kristin: They are. But also, I really liked doing the day shift. I did three days a week, so I was 24 hours. And our hospital considers that full time minimum to be able to get, like, full-time benefits, which is really great for a lot of people. And so when I first was working in the NICU, right before I transitioned, I was doing twelve-hour nights, and I was doing 24 hours a week. So it kind of ended up being about the same amount of hours. But obviously, I got paid a lot less, moving from nights to days, but now I'm back on nights. They needed an overnight person. The overnight person we had quit, and it just seemed like the right fit for me now, just in my personal life and what my needs were. But that's what I'm working now, and I actually really like it. So I'm the only one. I'm the only one overnight for the whole hospital.

[22:25] Michelle: Okay. That's what I was wondering. If you have a partner or if you're it.

[22:30] Kristin: No, I'm it. Yeah. I've been doing this for a little over three years now, so at least I have a good base. I feel good about doing it and being on my own, and I know what my resources are, but, yeah, I mean, if you would have told me maybe like a year ago that I would be a night shift by myself, I'd have been, like, crazy.

[22:53] Michelle: Well, how do you determine if somebody is a PICC candidate?

[22:57] Kristin: So there are certain criteria we look at. Obviously, a PICC line is a central line. So that's a huge thing. We don't want anybody to have a central line that doesn't need it. We don't want to have anybody that ends up with a central line. Blood infection, that's a huge thing now. But a lot of times we'll look at the main criteria. If they're on a vasoactive infusion, levo, dopamine, dobutamine, all that. If they're on any kind of infusion like that, longer than four to 6 hours, it can run through a peripheral IV for up to 12 hours. Not ideal, but it can happen. A patient that is unstable in the ICU, that has multiple drips running, somebody that is going to be getting discharged home with IV antibiotics, that's a big one. People go home with PICC's all the time. A lot of people don't realize that. It just helps patients get out faster. It used to be they had to be in the hospital get their IV antibiotics and stay there. But it's nice now that they can have their pick line get discharged and either have antibiotics at home with home health or go to infusion center and get those done as often as they need to. Or if there's a patient that has really poor peripheral access, if there's a patient that's getting blood draws all the time. Technically speaking, a PICC line is not indicated for just a patient who has frequent blood draws. But there are times that we have done that before. There are patients that come in with hyponatremia that need a higher percentage of sodium. It's just, it's really hard on the veins. And so those patients are automatically put in the criteria for a pick line. Also, for any patient that is going to be started on TPN, those patients get PICC lines as well. In the NICU, we have TPN and lipids that run through a peripheral IV all the time, as long as your dextrose content isn't greater than twelve and a half percent. And in the adult world, people freak out if they have a patient on peripheral TPN. I'm like, guys, it's really fine. It's okay. You don't understand. We did this in the NICU all the time, running through a 24 gauge IV. Okay, so it's almost okay. But those are kind of the main criteria that we look at. Like I said, if a patient is getting poked all the time and we're giving them lots of ivs that are going bad really fast, especially if they're on really on antibiotics, like vancomycin, that one. Obviously, if they get discharged on that, they get a PICC line placed. But there are patients that we know very well that come in frequently and they just have terrible veins. We have a hard time getting anything in them. And honestly, sometimes it gets to a point where we can't even get PICC lines in them. Either we actually have a list that we call or do not touch a list of patients that we cannot, we've tried putting in PICC lines, or they've gotten to the point where we can't get a PICC line placed. We either meet an occlusion in their shoulder or their chest and we've been unsuccessful and that happens too.

[26:24] Michelle: That was actually one of my questions is, what's the next step if the PICC line fails.

[26:30] Kristin: Yeah. So if the PICC line fails, and they do need central line access, depending on what the need is, for instance, if it's a patient that's going to be discharged on IV antibiotics, that's going to need a central line, we would defer to our interventional radiology. So we would have them contact them and say that we were unsuccessful. This is why. This is what happened. A lot of times they like to know. And then they will place a tunneled line under contrast so that they can see exactly what's going on. Or in a patient that is in the ICU that needs central line access, then their vascular surgeons would have to come in, or the intensivist or whoever is able to. Any physician who can place a central line will place a jugular subclavian. Subclavians aren't as common, or they'll do a femoral line. Next step. So that would be the next step after us.

[27:40] Michelle: Okay. Well, from start to finish, so you go in and introduce yourself and bring your kit and all that, and you stick and you measure and you tape and you x-ray. How long is this procedure taking?

[27:56] Kristin: So it depends. A lot of times when I'm explaining it to patients, usually the second I get there until I leave. Cleanups done. Everything, especially by myself. It usually takes a little bit longer, about an hour with a partner, depending on. As if the PICC line goes smoothly, it goes down and everything, which, by the way, we don't routinely do x-rays anymore for PICC line placement. Yeah, we actually use different technology. It's called three CG technology. We place a tracking device on the patient's chest. We put leads on, two leads. One on the right shoulder and then one on the lower left abdomen. And that connects to the tracking device. And then there's actually a wire inside our PICC line that tracker picks that up, and it can show us when it's going down into the SVC so we can see it if it goes, like, across, if it goes up the jugular. And then how we confirm placement is by the patient's heart rhythm. So our leads pick up our patient's heart rhythm. Just baseline. And then the wire inside of the PICC line that's picking up that PICC line rhythm, and we know we are in good placement. Once we get close to the SA node, we see a peak in our p waves, and so we want the tallest peak without a deflection or deflection, meaning that there's, like, a little down portion right before the p wave. Otherwise, we want it nice and tall, and it'll be a lot taller than their normal p waves that we're getting from those leads on their chest. So that's how we confirm placement. If our tracker is not reading right or they're an Afib or having issues, then we'll get an x-ray. But it's nice because a lot of times, as long as that works and we can see and we got our picture of our peaked p waves and everything, they can use it right away. So there's no waiting until we get a chest x-ray, which is really great. But, yeah, it takes about an hour. I would say 30 minutes with a partner. 

[30:11] Michelle: That is, like, way faster than I thought, because, well, again, you're working with adults, and, you know the procedure for kids, it's like, we've had nurses be in there for a few hours before, like, two nurses, and they're pulling it back out one cm, and then they're shooting another x-ray, and then they have to wait until the TPN is made, and it can take, like, several hours. So that's really cool that you can get that done so quickly.

[30:45] Kristin: Yes, it is. It's really great to just get it done. Now. There have been times when we've been in a room for two and a half hours. If we're meeting an occlusion somewhere, we have tricks to get past certain barriers. If it keeps going up the jugular, we have them turn their head towards us and their chin down to kind of block that jugular so it'll force it down. So there are different things that we can do to kind of get it to go where we want it to go, but it doesn't always want to do that. And everybody's anatomy is different, but there have been times when we've struggled. Sometimes just even accessing a vein can be difficult, and it can be very frustrating, for sure.

[31:33] Michelle: Well, talk about some of the technology that you use.

[31:38] Kristin: Yeah. So I talked to you about our three CG technology for confirming placement. I kind of touched on ultrasound IVs, just briefly, just saying that we did that. Ultrasound is the gold standard, really, for IV placement. A lot of people have always seen those vein-viewing things where it's the light from above, where that can show you veins, but it doesn't show you how deep they are. It doesn't show you how big the vessel is. It's just like, just that cross view of just like, oh, yes, they're there, but ultrasound is the gold standard. So with that, we have little centimeter marks on our ultrasound machine, and we can mess with the contrast and the brightness on our ultrasound machine. I'd be like, what are you guys looking at? I never knew what anybody was looking at on an ultrasound, and every ultrasound is different. So I was always like, I don't know how I'm going to do this, but it's relatively easy. Basically, just look for these dark circles that are so the veins and the arteries look the same. They're these dark circles with blood flow. Right. And how we tell the difference is we'll push down on that vein, and if it collapses, that means it's a vein. And if we push down and it doesn't collapse all the way, and you'll see the heartbeat, you'll see it kind of talking to you. That's your artery. So it's like, okay, yes, we don't want that. We want our vein. And that has been definitely something totally new and foreign to me. But let's see, when did I train for ultrasound IVs? Because that's been become more of a thing before. Most of my time so far as an IV team PICC nurse has been only doing IV's just by touch and feel and by sight. But what we're finding is people are sicker, especially post-COVID. People are coming in more frequently. People are waiting, unfortunately, too long, especially during the pandemic. And then people are just way more sick than they used to be. And so because of that, people's veins just aren't as great anymore. And so we had a couple of people that were already ultrasound trained that came from other facilities and they were wonderful resources to have and kind of gave us a push to actually start training everyone that was interested, if not all of the staff, to place peripheral IV's with ultrasound guidance. So I had just learned this skill in October of last year, so it's, like, really new for me. And so I learned that right before I went to nights. And so it's been a very good skill to have when it's just me, myself, and I. And it's actually been able to push me with that skill even further and use it a lot and kind of hone that skill in. So it's amazing. I love it. It's so cool how you can see how big the vein is. We have guides on the side that can give us the size of what we would need for a 22, 24, 20 gauge. 18 gauge. So most of the time I just use either 20's or 22's. But when I use an ultrasound to get an IV. I use a 20 gauge, but you don't have a guide to guide you to a depth, so you kind of just have to base it off of, okay, this is deeper. I'm going to increase my angle or decrease for more shallow veins. But it's something that's really neat because then you can actually see the needle come down and then get into the vessel and the center of your vessel, and then you just slowly, like, you lower and advance your needle and you can see it in the center, and it's, like, so satisfying to see that. And then you just catheter, and then you can see your blood return. It's really great, but really, that's something that I've really enjoyed learning how to do within the last few months, and it's been amazing. And patient satisfaction with that has been incredible, too.

[35:51] Michelle: Wow. So do you use that every time, or do you just use it? Do you go in first and assess and see if they have decent veins? And do you just pull that out when you're like, I can't feel anything or see anything?

[36:08] Kristin: Yeah. So unless it's a patient that I know doesn't have anything, I will go in. If I get called for an IV restart, I always look at the room number, see who the patient is, and if I know them. If not, I'll just go and assess first. And I always try to find something without the ultrasound. Ultrasound is something we actually charge for, so I honestly don't know how much, but it's a charge that we have to do, so I have to think about that, too. Only do it if the patient needs it. So a lot of times I'll go in there and assess for, see if I can feel anything. If I can't, then I'll get my ultrasound. Now, if I feel like there's one that I'm like, oh, I don't know, I'm going to just try. We're just going to see. And I don't talk to the patient about the ultrasound unless it's something that I'm like, oh, yeah, we really need to do. I'll usually try if there's something I think that I really have the potential of getting, and if I'm like, no, there's nothing, I'm not going to waste my time. We're just going to go for the ultrasound. And a lot of patients have never heard that or it's a patient that I've never seen before. But as I'm looking and assessing, I'm like, oh, gosh, your veins are small, you don't really have much. I usually ask them, have they ever used an ultrasound on you before to get an IV? And sometimes they'll say no. Other times they'll be like, oh, yeah, they do. And I was like, okay, well, let me go grab that. I don't ever want to lose my skill with touching and feeling. That's something that's super important to me, that I always want to have and keep, and I don't ever want to lose that. So I only want to use ultrasound when it's necessary. Or if a patient's gone through multiple IV's, then I'm like, okay, maybe we should try the ultrasound. I'll just kind of look into it before I go to the room if I have time. I don't always have time for that, too.

[38:04] Michelle: Yeah, that's cool that you have that tool at your disposal.

[38:08] Kristin: Yeah, it's really neat.

[38:10] Michelle: So do you routinely premedicate the patient, or is that something that's just on a patient-by-patient basis?

[38:19] Kristin: Premedicate for what?

[38:21] Michelle: Well, you know how we premedicate the infants with morphine or Versed or something? Yeah. If you have somebody who's really anxious, would you consider that, or do you just kind of go for it?

[38:40] Kristin: I would love to premedicate everybody. Oh, gosh. Yeah. And I'm sure a lot of patients would love to be medicated.

[38:52] Michelle: You would have to medicate me. I guarantee it.

[38:55] Kristin: Oh, my gosh. No, you would be totally fine. And honestly, a lot of times when it's done, people get very anxious about this, and I totally get it. I would be, too, if I knew nothing about it. Never had one. My dad actually had a PICC. He had two PICC lines, but I was never around when he had it placed or anything, obviously. But before that, I didn't know anybody about getting a PICC line and going home with it and being on antibiotics and stuff. Yeah, I would normally be terrified. And honestly, I wish we could medicate some people because it is anxiety-inducing, it is scary. It is stressful. It's something that a lot of people have never been through before. But I like to explain it really well. I talk to them the entire time, and explain what I'm doing. Some people don't want to know. They're just like, just do it. I'm like, okay, I'll shut up. I won't talk to you. It's okay. Fine. Or, you know what? If you want to talk, I'll talk to you about anything. We're done. And they're like, oh, my gosh, we're done. And a lot of times like, oh, my gosh, that was not as bad as I thought it was going to be. And I'm like, see, I told you you're okay. When I was working days we'd go in pairs, all of us on the IV team, we love our jobs. We know how lucky we are. We love what we do. We're obsessed with it. We're good at it. We like working with each other, really, for the most part. We're like family and we work with each other all the time, so we know what the next step is. It's literally the same steps every single time. It doesn't change. It's like when you fly, it's the same safety steps, it's the same this, same checks, they talk about that. And like the airline world where it's like, it's always the same thing every single time. And you don't skip anything because if you keep it the same all the time, same safety check, the same everything, the room for error minimizes. And so it's like that in the PICC world where it's the same things. You know what the next step is going to be. You know what that person likes. Everybody has their own little ways of doing things, but it's the same thing every time. And there's comfort in that. But there's also comfort in the patients when they see us doing it and just boom, but a boom, but a boom. We know what we're doing. And they're like, okay, they know what they're doing. You guys work really well together. You guys work together all the time, don't you? They'll say that all I'm like, yeah, we do. We really like it. And people can see that and it gives them peace, I think, too, just knowing that. But there are patients that will let talk to the nurse usually knows. They're like, oh, yeah, they've been really anxious about this. Honestly, we can't medicate before we get consent because usually we go to the bedside, we get consent, and then we do the procedure literally the same right then and there. So really have people that are going to be sedated or too groggy to get consent, but there are times where we'll get consent before and then we'll plan it and a nurse will get an order for Adavan or whatever they deem appropriate or if a patient can just have some pain medicine at that time to kind of time it that way. But routinely, no, we don't premedicate yeah, I wish we did, though. I think it would take a lot of anxiety away from patients.

[42:19] Michelle: It's great that they see your competence and also the teamwork. I think, as a patient, to see professionals working closely together like that, brings them a lot of comfort. So that's great. Well, I noticed that there were quite a few professional organizations related to vascular access. So there's the Vascular Access Society, the Society for Vascular Nursing, and the Association for Vascular Access. And then there is a special certification, the vascular access certification, which is the VA-BC. And then there's also a certification for PICC Ultrasound Inserter. Have you heard of any of those, or do you have any of those certifications?

[43:13] Kristin: I do not have any certifications yet. I'm debating on which one to get. So the VA-BC is one that my good friend and coworker, Angie, has. She has the VA-BC, which is more applicable, I think, to what we do more just about vascular access itself. The other main one that people will get, which I think there's two nurses on our team that have, is the INS certification, and INS, they're the ones that dictate a lot of our guidelines. So it's the Infusion Nurse Society, but the INS certification involves actual infusions and that whole part of it, and different medications and what to do for them. And so it's more broadened than what we actually do, which is more just solely the vascular access part, which we include some of that knowledge in what we do. And it's important, but it's a little more comprehensive and it can be a little overwhelming. But I'm debating on which one I want to get. I haven't decided yet.

[44:32] Michelle: Okay. How do you keep up to date on best practices?

[44:37] Kristin: So, like I said, the Infusion Nurse Society, they come out with standards. However, there are times, like recently, some of the newer practice guidelines involving pick lines that end up getting DVTs in that arm. Practices have changed with that, but it doesn't necessarily translate to what we do in the hospital quite yet, because we know things change all the time. And to get anything changed or procedure changed or just even a change in practice with physicians can take some time, but with that, that's changed, and that's been guided by the INS. So that's kind of the gold standard in our Bible, basically. Yeah.

[45:29] Michelle: Okay. That one I hadn't heard of, so I'll put that one in the show notes, too. So how much experience do you think I need as a nurse before becoming a PICC nurse?

[45:42] Kristin: Well, I do think at least like three or four years in nursing is best. Just to have that nursing experience and that critical thinking and just experience in being a nurse and everything that comes with that, I think is important, maybe even up to five years. But that's not necessarily a hard role. And it hasn't been for our team. We've had a lot of staffing changes just due to people retiring or people moving, and so we've had to hire people for our team. But it's hard to find people that actually do have solid IV experience. I mean, that's the main thing. The main thing is IV experience is just the big thing. Just that you're decent at it. You don't have to be an expert or a pro, but you get most of your six and you're teachable and you don't necessarily have to have any experience, like obviously doing PICC's and stuff. But I would say just to make sure that it's something that you are going to really enjoy. Do you need like a few years of experience as a nurse? If not at least a couple of years, just to at least have that base and then obviously IV access experience.

[47:10] Michelle: It sounds very practical. I think two years sounds really good. It gives you enough time to do a lot of IV sticks, hopefully, and to improve on that skill and also to learn critical thinking and stuff, like you said. So what can I start doing today if I'm a nurse and let's say I hear this podcast and I'm like, that sounds like my jam, I want to do that. What can I start doing today if I want to become a PICC nurse?

[47:47] Kristin: So I would say if a nurse is interested in doing it, do every IV you can all the time. It's one of those things that I always tell people, we have nursing students who will come and spend time with us, and always tell them doing IV's is not something you're born with, it's a learned skill. So nobody's born with just being amazing at IV's. You have to do it and you have to be willing to just do it and you're going to fail. I fail all the time. There are times when I don't get and it drives me nuts. And as an IV nurse, we pride ourselves on getting it in the first stick. That's the goal. That's the goal always to just poke once and be done with it. But that doesn't always happen. So it can be frustrating for anybody with however amount of years of experience you have, but just get started to just do it. And if you're looking for a really basic resource. The IV Guy on, I don't know if he has a YouTube channel, but I know he has an Instagram.

[48:47] Michelle: He's amazing. I follow him on Instagram.

[48:50] Kristin: Yes, I love him. And when I was in the NICU and just kind of like when I'd heard about the IV team and my coworker in the NICU working on it, and I was like, I need to get better at my IV skills. And so I just, even just looking and watching his videos on Instagram and the tips and tricks he gave, I mean, it increased my success rate a ton just by those little things. And so even just that, that makes a huge difference. But just actually just doing, you know, not every hospital has an IV team, but we actually contract with Nebraska PICC Specialists. They are a company, a group of people, nurses that are PICC  certified, that do PICC lines, midlines, and they're contracted with different facilities, different hospitals within Nebraska, Kansas, Iowa, and they travel and go to facilities that don't know a PICC team or the staff there to do it, and they'll place those lines for them. So there are those services all throughout the nation and all kinds of states. So if that's something you want to do, a lot of times those people, they may want somebody with experience, but not always. A lot of places are usually willing to train. If it's somebody that's really like, I want to do this, I'm passionate about it, because that ultrasound skill, obviously, it's not something that you really normally have an experience to get at just any hospital. However, I will say that there are some hospitals, especially some nurses in the ER or maybe in the ICU setting, that may learn how to do ultrasound guided ivs or even place midlines. There have been a couple of people that have helped on our team that, oh, yeah, I've been doing midlines for years. I did it for such and such a hospital. So that happens, too, where some facilities are looking into having nurses get trained to do those, which can be super helpful. But yeah, I think the biggest thing is just get out there, do those IV's, find your good resources, like within where you work your unit, find your IV buddy that's just going to be there with you and give you tips or learn from them. And then the IV Guy is really great. He's a really great resource, for sure.

[51:07] Michelle: Okay, cool. And if your hospital doesn't have an IV team or a PICC team, then start one, right?

[51:15] Kristin: Absolutely. Yes.

[51:17] Michelle: Go to your administration, say, hey, there's a need for this, and I'll be first on the team.

[51:24] Kristin: Yeah, absolutely. Because honestly, it does increase patient satisfaction, and that's a huge thing, obviously now. And I mean, patients, they are so happy when they find out that there's an IV team, and I get called. They're like, yeah, they tell me stories of them getting poked, like, ten times and this and that. All of us have had horrible experiences with getting poked, whether that's for labs or an IV. And so it's a huge increase in patient satisfaction, for sure, because most everybody needs an IV and most everybody hates getting poked and gets anxious about it. So when you have an expert that can do it, it's really nice.

[52:07] Michelle: I would think along with patient satisfaction, nurse satisfaction has to be really high. Knowing that they can call somebody if maybe they're having a bad day with their IV skills or whatever it is, it's just something to take off of their plate. And so I would think that you guys providing that service are just like a huge help to the nursing staff.

[52:32] Kristin: Oh, absolutely. And I know they have so much on their plate, as you said, and they're so busy, and if it's one less thing they have to worry about, I'm happy to do it, especially on a patient that is a difficult poke where you do need an ultrasound, and sometimes that takes time that a lot of nurses don't have. Right. And so having somebody that can do that for you, and honestly, everybody's always so grateful. And that's one thing. We didn't always have somebody overnight. Overnight, a lot of the nurses, most night nurses were more comfortable starting IV's than the nurses on the day shift. But if they didn't, then it would be the house supervisor. So during the pandemic, we were able to offer and saw the need for an overnight position. So that's been kind of a newer thing within the last couple of years. That's why I'm really grateful, and I know they're super grateful to have me on the night shift. It takes a lot of stress from them. And we don't have to use Nebraska PICC Specialists who we contract through over the weekend because we don't have coverage overnight for our IV team at the. So. But, yeah, the nurses I know greatly appreciate it, and I know it's something that is just one less thing they have to worry about, and I can take care of that for them and they can just move on with everything else they have to do.

[53:55] Michelle: Yeah. I think you're a great asset to first the patient and then the nursing staff and the hospital. I think it's great. So we're going to get ready to wrap up here, and I have a couple more questions for you. So this question, I just started asking it with one other guest, and so you're the second guest that I've asked.

[54:19] Kristin: Okay.

[54:20] Michelle: So is there anyone you would recommend as a guest on this podcast? Nothing like being on the spot.

[54:32] Kristin: I know.

[54:34] Michelle: I don't know.

[54:35] Kristin: Just anybody, obviously. Like somebody that's a nurse.

[54:40] Michelle: A nurse that you found interesting or somebody that you know or you don't know. Maybe the IV Guy. Maybe I need to get the IV Guy on the podcast.

[54:53] Kristin: You know what? And you should talk to my husband, Gabriel, because he's amazing and he's going back to school and, yeah, just because I love him so much.

[55:03] Michelle: I think Gabe is amazing. I would love to talk to him. And I even have to look far to get his contact information.

[55:11] Kristin: No, you don't.

[55:15] Michelle: Okay, well, where can we find you? If we have questions, where can we find you?

[55:21] Kristin: Well, I am on Instagram and really, that's it. I am not big on social media, but you can find me on Instagram for sure.

[55:34] Michelle: Okay, well, we've reached the end, and you know what that means. It's time to play the five-minute snippet. Are you ready to play?

[55:44] Kristin: Yes, I am.

[55:46] Michelle: It's just five minutes of fun, Kristin.

[55:49] Kristin: Okay, buckle up.

[55:50] Michelle: Okay. Can't possibly go wrong. Okay, I'll start my timer. Okay. What's the first impression you want to give people?

[56:02] Kristin: I want people to feel safe with me in whatever capacity that means for them.

[56:08] Michelle: Would you rather be 11ft tall or nine inches tall?

[56:14] Kristin: I think I'd rather be 11ft tall. I mean, that would be difficult in ways, but I'm 5'4", so I'd love to be tall.

[56:24] Michelle: It kind of be hard to start a PICC line if you're only nine inches tall. Right?

[56:30] Kristin: I would need a special bed that would come all the way up to me. Yeah, that'd be something.

[56:36] Michelle: Oh, gosh. Okay, well, we're one day late on this question. Chiefs or 49ers?

[56:43] Kristin: Chiefs for sure. I'm in. Come on now. We're, like, right there.

[56:50] Michelle: No. So true. Okay. Is there a brand or a product that you buy because it's trustworthy?

[57:00] Kristin: Yes, I would say my skincare.

[57:03] Michelle: Super important.

[57:05] Kristin: Yeah. That's the only thing that I could think of.

[57:09] Michelle: Okay. Would you rather wear the same socks for a month or the same underwear for a week?

[57:19] Kristin: Oh, boy.

[57:22] Michelle: You're like, I can't win with this one.

[57:28] Kristin: I can't think about either one for too long. Honestly, I sweat a lot. I run around the hospital, so either one is not great. I love it, the logistics of that. Okay, boy, I think I'm going to say you like, pass.

[57:53] Michelle: Can I pass?

[57:56] Kristin: I'm going to have to say the socks. I don't know if I could do the underwear, even though it's for a shorter time. That's a whole nother.

[58:03] Michelle: Okay.

[58:04] Kristin: Yeah. Okay.

[58:06] Michelle: Cats or dogs?

[58:08] Kristin: Oh, both. I love both. Yes. I have a cat, actually. Now. I have a hairless cat, and he's amazing. And we had a dog for a while, but he recently passed. But I love both so much, so I can't decide on that.

[58:22] Michelle: Okay. What do you do when you want to get out of your head?

[58:28] Kristin: I listen to music.

[58:30] Michelle: Any particular genre?

[58:36] Kristin: I like pop. I like Alternative. Sometimes, actually, if I'm really just needing to just relax and try to shut off my brain, there's this Soundbath playlist that I really like to listen to on Apple Music. Or I'll just play with my four-year-old because I just need to just be silly and get out of my own adult head. So singing works pretty good for me.

[59:02] Michelle: Kids are good for that.

[59:04] Kristin: He really is. They are. They're amazing.

[59:07] Michelle: Would you rather have a sing-off with Adele or a dance-off with Shakira?

[59:16] Kristin: Well, I think I'd be way too. I mean, I love Adele. I love both, actually. But I think I'd rather just do a dance-off and just be silly. Adele's way too good. I mean, Shakira is great, but Adele's going to make me look like a fool. Shakira will look like a fool, too, but it'll be more lighthearted, I think.

[59:38] Michelle: I think your energy matches Shakira more like, I could see you just really getting down.

[59:46] Kristin: Getting down. Yeah. Try to shake it like Shakira.

[59:50] Michelle: Right. Okay. Cookies or chips?

[59:54] Kristin: Chips. I'm more of a savory kind of gal. I mean, I love sweet. I love salty and fried.

[01:00:00] Michelle: Do you guys have cheese curds there?

[01:00:03] Kristin: Yes.

[01:00:04] Michelle: Nebraska.

[01:00:05] Kristin: No, that's more like Fort Worth. But, I mean, yes, we do, but that's not, like, what we're famous for. I mean, what are we famous for?

[01:00:14] Michelle: Yeah. What are you famous for?

[01:00:17] Kristin: Corn.

[01:00:18] Michelle: Yeah.

[01:00:19] Kristin: We're the Corn Huskers now.

[01:00:21] Michelle: Right?

[01:00:23] Kristin: Yeah. And you know what a weird thing is? I know this is really random and off, just a side note, but out here in Nebraska, like, chili and cinnamon rolls are, like, a thing.

[01:00:34] Michelle: I mean, those are kind of like comfort foods.

[01:00:37] Kristin: Yeah.

[01:00:38] Michelle: So that makes sense. Because it's hella cold there.

[01:00:42] Kristin: Oh, yeah, tell me about it.

[01:00:44] Michelle: Yeah. After living in California, right?

[01:00:48] Kristin: Yeah, I miss the weather.

[01:00:51] Michelle: Okay, last question. Would you rather walk to work in high heels or drive to work in reverse?

[01:01:00] Kristin: Oh, my God, I'd be horrible with both, but I think just for everyone's safety I should just walk in high heels.

[01:01:09] Michelle: I hope you don't have to walk far.

[01:01:11] Kristin: I would have to walk, like, 10 miles.

[01:01:14] Michelle: Oh, shit.

[01:01:16] Kristin: And I don't do well in high heels, but just save everybody else from me driving backward in the snow. No, I would break something for sure.

[01:01:29] Michelle: Oh, gosh. Well, see, you did it. You passed the five-minute test and it was fun, right?

[01:01:36] Kristin: It was. Yes. Thank you.

[01:01:38] Michelle: Yes. It's been really fun having you, Kristen, and reconnecting. Yes. I want to reach out to Gabe. I think he would be amazing as you. So thank you for coming on today and teaching us all about what it means to be a PICC nurse.

[01:01:54] Kristin: Of course. I love my job. I'm obsessed with it. I'm so blessed to do the work that I do. And thank you so much for having me. It's been amazing talking to you, and reconnecting. I've missed you so. I really appreciate it. Thank you for having me.

[01:02:13] Michelle: Well, if you're in Visalia anytime soon, stop in, and let's do lunch or something.

[01:02:19] Kristin: Absolutely. That sounds fantastic.

[01:02:22] Michelle: All right, take care, Kristin.

[01:02:23] Kristin: Great. Thank you.